Post-Discharge NP: Transitional Care Leader

legacycommunityhealth; Houston (TX); On-site; USD 105,000 - 140,000; Full time

Benefits offered by this job

Paid Time Off & Holidays

Medical Insurance (Medical)

Dental Insurance

Vision Insurance

Life Insurance

Flexible Spending Account (FSA)

403(b) Retirement Plan with Company #

Short-Term & Long-Term Disability

$0 Copay for Legacy Provider visits

$0 Copay for prescriptions filled at 0

Travel Insurance

Pet Insurance

Subsidized Gym Membership

Job summary

Legacy Community Health in Houston is seeking a Nurse Practitioner for Transitions of Care to support patients after hospital discharge. You will coordinate care, reduce readmissions, and collaborate with the care team to ensure seamless transitions back to daily routines.

Responsibilities include conducting post-discharge visits, reviewing discharge summaries, creating individualized care plans, and reconciling medications.

Qualifications

• Texas NP license (or eligible) required.
• 2 years of experience in transitional care or care coordination preferred.
• FQHC clinic experience preferred.
• Transitional Care Management experience desirable.
• Strong communication and organizational skills.
• Proficiency with EHR systems.

Responsibilities

• Conduct post-discharge visits for recently discharged patients.
• Review discharge summaries and medical records for comprehensive care.
• Develop and communicate individualized care plans.
• Perform medication reconciliation and address discrepancies.
• Coordinate follow-up with primary care and community resources.
• Escalate urgent concerns and document care encounters.

Skills

Post-discharge care

Care coordination

Patient education

Team collaboration

Spanish helpful

Education

NP license TX

Master of Science in Nursing

Tools

EHR systems

Job description

Legacy Community Health in Houston is seeking a Nurse Practitioner for Transitions of Care to support patients after hospital discharge. You will coordinate care, reduce readmissions, and collaborate with the care team to ensure seamless transitions back to daily routines.

Responsibilities include conducting post-discharge visits, reviewing discharge summaries, creating individualized care plans, and reconciling medications.